New Findings on Medical Marijuana For Chronic Pain

October 9, 2015 / Thomas Cohn, MD

New research out of Canada suggests that medical marijuana may help people with chronic pain control serious side effects, but it may lead to an increase in minor side effects.

Lead researcher Dr. Mark Ware said medical marijuana appears to be a relatively safe option.

“In terms of a side effect profile, we felt the drug had a reasonably good safety profile, if you compare those effects to other medications,” said Dr. Ware, director of clinical research at McGill University Health Center in Montreal.

Medical Marijuana Study

For their study, researchers tracked 215 patients with chronic pain who used medical marijuana. Participants were studied for one year, and they were compared to a control group of 216 individuals who did not use medical or recreational marijuana. Individuals in the medical marijuana group were given leaf marijuana containing 12.5 percent THC, and they were allowed to smoke it, eat it or vaporize the substance.

At the conclusion of the study, researchers uncovered:

Those who used medical marijuana to ease their chronic pain did not have an increased risk of serious side effects, compared to those who didn’t use pot.

Medical marijuana users were more likely to experience minor side effects, like headaches, nausea, sleepiness and dizziness. They saw a 73 percent increase in less-serious side effects.

Researchers suggest medical marijuana users saw some pain relief through the use of the drug, and they also had better moods and reported a higher quality of life.

Dr. Ware said the study was the first and largest in terms of the long-term safety of medical marijuana, and it could help people who are deciding whether or not to try medical marijuana for their chronic pain.

“This is a paper they should bring to the attention of their physician or health care provider,” Ware said. “Anybody who is interested in using cannabis to treat pain should know this information, as it can influence the decision-making process considerably.”

Dr. Ware also said patients who have never tried marijuana my have a different experience when first getting used to medical pot

“For somebody reading this who’s never tried it, the effects they experience might be different,” Ware said.

Minnesota on the Eve of Medical Marijuana

June 29, 2015 / Thomas Cohn, MD

Recently there have been excellent reviews on the state of the science of medical marijuana. Minnesota is about to start its program, but only a handful of people have been approved for the program and there are not many providers interested in participating. So why is medical marijuana off to such a slow start in Minnesota?

Medical cannabis is a complex subject, after attending many lectures on the subject, and reviewing significant amounts of literature, the one main conclusion is that the science behind cannabinoids is only in its infancy. For the average reader, the Time Magazine May 14, 2015 and the National Geographic July, 2015 issues have good information. At a higher level for medical science, the June 23/30, 2015 issue of the Journal of the American Medical Association has more data.

US Lags Behind

The United States has not been a leader in the study of marijuana. Since marijuana has been labeled a Schedule 1 compound by the DEA, its scientific analysis in the U.S. has been extremely limited. Some of the best research initially has come out of Israel where many of the cannabinoid compounds have been isolated, and in Spain where some of the cancer research and other studies have been done. The most recent issue of JAMA has reviewed a large number of medical studies with regards to a variety of conditions. For the scientist, it is clear there is a significant shortage of information supporting claims of effectiveness of the compounds for most conditions. Most information is based on a very limited numbers of study participants. Comparing the information to almost all other drugs on the market, these studies would barely qualify for drug approval.

The quality of studies for marijuana and chronic pain has been especially limited. The studies researched include neuropathic pain and cancer pain. Most of the studies just looked at a numeric pain scale to measure success and did not quantify any other objective measure like functional ability. The outcome was a modest improvement in reported pain level, but deeper evaluation did not show any changes in quality of life measures when compared to placebo or standard treatments.

After reading multiple articles on cannabinoids and pain, one clear message is present. First, there are a number of different cannabinoid compounds, probably well over a hundred. Second, the chemistry is poorly understood and the effectiveness to treat a variety of medical conditions is limited. Medicine has become a very science driven field. Physicians are constantly under fire to provide care that is safe and effective. The current status for medical marijuana is truly still in the research phase. We won’t be able to fully embrace medical marijuana as a viable option until we know more about all of its compounds.

What Pain Professionals Are Saying About Marijuana

March 23, 2015 / Thomas Cohn, MD

Marijuana is a controversial topic in society. Some people want it legalized while others demonize the compound. The reality in the medical field is somewhat in the middle. The first thing that needs to be understood is that in most circumstances, medical experts are primarily interested in all the compounds in marijuana except for THC. That means most medical professionals are interested in what cannabinoids or cannabidiols (CBD) compounds are present and what medical purpose they serve. The major compound that is present in almost all available marijuana is THC, which also happens to be the compound responsible for the high one receives from marijuana.

For pain professionals, there is good understanding of the action and effects of THC. Most strains available in states that have legal marijuana, including strains that are “medicinal” in use have high amounts of THC, 10% or greater in amount, and virtually no other cannabidiols, or less than 2%. In the years of the hippie generation, the 1960’s and 1970’s, THC to CBD ratio was 1:1, and averaged 1-2%, while the really good stuff was just around 5%. Now available in legalized states, most available strains are minimum of 10% with up to 30% THC.

Medically, the best comparison of legal marijuana at this time, is to alcohol. The risk of dependence to THC is about 9%, including when using once a week (in reality this is a very strong way to become dependent), compared to alcohol which is 15%. Regular use, once a week, is known to increase depression, suicide, impulsivity, schizophrenia and psychosis, especially if use is started under the age of 20. It also leads to an 8-point loss of IQ in the young. Further, smoking does cause problems with the lungs. Recommending regular marijuana is no different for medical professionals to recommending drinking alcohol. The risks and associated problems are clearly out numbering benefits.

Need To Understand More

What we know about cannabidiols is just the beginning. In marijuana, we know there are over 100 different types. Our experience so far has found that they have some properties that may be helpful in about 30% of patients with neuropathic pain associated with MS and HIV. In low back pain, we’ve learned:

It has helped in anxiety but not with pain.

More people respond to acetaminophen then marijuana.

The future of cannabidiols is interesting for pain. It is unlikely that many professionals would be enthused to prescribe a substance that has the risk profile of THC. Once we can find the particular cannabidiols that have medical uses, it is likely that we will try to study them fully and make them commercially available for specific conditions. Cannabidiols may be helpful in the future, but we still don’t know enough right now to safely prescribe marijuana for a wide range of conditions.

Marijuana and the Reduction in Painkiller Overdoses – Part 2

September 10, 2014 / Thomas Cohn, MD

Last month we discussed the new study published in JAMA (The Journal of the American Medical Association) showing that drug overdose deaths due to opioids declined in 13 states that legalized medical marijuana. The study just looked at death rates overall due to opioids and noted that they happened to decline up to 30% in states that legalized medical marijuana. Today, I expand on the findings.

This study is great, sensational news, but in reality, it is a leap of faith that these two subjects are truly correlated. Opioid overdose and deaths are a very complex issue. The overdose of opioids is linked to many things, especially recreational use. The death rate from overdose is related to many factors, including whether the overdose was accidental or on purpose, such as a suicide. Furthermore, the access to treatment for overdose is important, especially whether first responders can recognize it and provide drug reversal rapidly and then get a person to a hospital for support. So, if you are using opioids to get high, it does not matter if marijuana for medical use is legal since they are not using it.

Medical marijuana is used for a variety of problems, including nausea related to cancer, seizures, and glaucoma. None of those conditions have much to do with opioids and drug overdoses. So if marijuana is legal for glaucoma or treating seizures, why would death rate due to narcotic overdose change? Rationally, it would not.

Unfortunately, this is just another example of a study finding a nice statistic that has no true correlation to the data. This study did not specifically look at factors that are related to opioid overdose death. If the study actually looked at reasons related to opioid overdoses, treatments, and deaths, there may be some validity. Rewarding medical marijuana with this lofty success is poor research and data interpretation. A prestigious journal, JAMA, should do much better at critically analyzing research and publishing articles. This is an amazingly poor job of data analysis and conclusions with an over simplification of causes of opioid related deaths.

Medical Marijuana For Chronic Pain in Minnesota

July 2, 2014 / Thomas Cohn, MD

Minnesota has taken a conservative approach to the use of marijuana for medical purposes. Only a little quality research has been done with regards to the use of marijuana for pain. Most of these studies have been done for patients with cancer or eye problems, and current research is focused on seizures.

The reason why marijuana research is moving slowly is because there are all over 100 compounds that may be an active in cannabis. Most medical professionals would like to know both the positive and negative aspects of any intervention. Since there is no significant marijuana research available, it is hard for medical professionals to recommend the use of this compound.

Marijuana in Minnesota

Minnesota’s new marijuana laws allow the use of marijuana for only limited medical diagnoses. At this time, chronic pain is not included in the list of treatment recommendations. Chronic pain is extremely complex, and has multiple causes in most people. A single compound like marijuana is unlikely to be helpful and every person. Determining which group of patients would be helped by such a compound will be difficult due to the variety of conditions that cause pain.

Most physicians in Minnesota will not be prescribing medical marijuana. If you have chronic pain, do not expect a physician to write you a prescription for marijuana, especially since it isn’t approved for recreational use in Minnesota or even nationally. Furthermore, the drug enforcement administration (DEA) can stop a physician from being able to prescribe any medications if they prescribe to known drug abusers. The use of marijuana is not considered a legal medication, and physicians can lose their license if they prescribe to a patient who abuses marijuana.

Alleviating Symptoms

Pain symptoms in some patients may seem to improve with the use of marijuana. There are many compounds in marijuana that may help control a variety of symptoms including anxiety and pain. Most physicians who are prescribing control medications such as narcotics will do a urine drug screen to determine whether street drugs are being used by the patient. Most physicians have a zero tolerance rule for the use of street drugs since they could lose their license if they prescribe to an abuser. If you use marijuana, do not expect to be prescribed narcotic medication. Most pain physicians will work with you to control your symptoms with other treatments that are very effective in managing your problems.

In the distant future, when we know which compounds in marijuana are effective, we may be able to develop more comprehensive treatment plans for patients with chronic pain. Until that time, hopefully the change in laws will promote good research with regards to the active compounds that will be effective in managing pain. More tools to treat pain will always be helpful. Unfortunately, research takes time and these new compounds may take up to 10 years or longer to develop.